CDS Connect: Neurology: Traumatic Brain Injury (TBI) Documentation Template

Neurology: Traumatic Brain Injury (TBI) Documentation Template


The intent of the “Traumatic Brain Injury (TBI) Documentation Template” is to provide information from the referring provider to the consulting specialists, for a number of consults relevant to the management of TBI patients. This documentation template is used in conjunction with another one used for the TBI screening itself, which also supplies information to the consulting specialists. This template supplies information specific to the consult request process, and is completed automatically, only when the referring provider has indicated intention to consult relevant specialties in the “TBI Screening Documentation Template”.

Artifact Type
Creation Date
Unique Identifier

Artifact Creation and Usage



Donald Higgins, MD, National Program Director of Neurology 810 Vermont Ave NW Rm 668 Washington, DC 20420
Glenn Graham, MD, Deputy National Director of Neurology 810 Vermont Ave NW Rm 670 Washington, DC 20420
Ellis Boudreau, MD, Staff Neurologist, Portland VAMC Portland VAMC 3710 SW US Veterans Hospital Road Portland, OR 97239
Jason Sico, MD, Physician, VAMC Connecticut VAMC Connecticut 950 Campbell Ave West Haven, CT 06516
Michael Phipps, MD, Neurologist, VAMC Baltimore, Baltimore VAMC 10 N Greene St Baltimore, MD 21201
Sarah Maulden, MD, Assistant Professor of Neurology 550 Foothill Dr, Ste 400 SLC, UT 84113
Joel Scholten, MD, National Director, Physical Medicine and Rehabilitation, 50 Irving St NW Washington, DC 20422
Lisa Perla, , Rehabilitation Planning Specialist, 31 Hopkins Plaza, Room 1250 Baltimore, MD 21201

Please contact Mr. Apurva Desai for additional information.

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.

Copyright © 2018 Veterans Health Administration, Department of Veterans Affairs. All rights reserved. Contributions from external parties are property of respective copyright holders.

Implementation Details
Technical Files
Repository Information
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage


Target User
Primary Care
Clinical Focus
Adult patients with suspected Traumatic Brain Injury
Clinical Venue
Patient Age Group
Adult patients
Patient Gender
Workflow Task
Request Neurology Consultation


Supporting Evidence
Source Description


Derived From
Neurology: Traumatic Brain Injury Screening Clinical Content White Paper
Associated Resource
Neurology: Traumatic Brain Injury (TBI) Documentation Template Conceptual Structure Document
Associated Resource
Neurology: Traumatic Brain Injury (TBI) Documentation Template KNART Validation Report




See attached resource files for additional details. Department of Veterans Affairs, Veterans Health Administration, Office of Informatics and Information Governance, Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs) Eye Care Clinical Content White Paper, VA118-16-D-1008, Task Order VA-118-16-F-1008-0007, June, 2018.

Mild Traumatic Brain Injury Rehabilitation Toolkit. Army Medical Department Center and School ( AMEDDC&S ), U.S. Army Health Readiness Center of Excellence ( HRCoE ) website. Accessed August 28, 2017
Management of Concussion-mild Traumatic Brain Injury (mTBI), Version 2.0 – 2016. VA/DoD Clinical Practice Guidelines website. Management of Concussion/mTBI Working Group. Published February 2016


Artifact Representation
Testing Experience
Pilot Experience